On the Brink of Guinea Worm Extinction: History in the Making!

By Sinéad O’Ferrall (@SineadOFGH)

Diseases can often be stomach turning, but for most people nothing has more “ick” factor than parasitic infections . Yet this does not diminish the seriousness of these diseases and the burden they place on the most vulnerable people in the poorest countries. Malaria, perhaps the most well known parasitic disease, is one of the leading causes of death and morbidity in developing countries.

Parasitic diseases cover a wide range of disease presentations, from the well-known ones such as malaria or ringworm to the more obscure ones like onchocerciasis (also known as river blindness or Robles Disease). So what links all these varying diseases? What distinguishes a parasitic disease from any other disease?

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Young child with ringworm infection on the cheek. Credit: Sinéad O’Ferrall

Well, a parasite is an organism that must inhabit another host to survive, at the expense of the host. It can be a temporary host to support one life stage of the parasite such as in the case of schistosomiasis, or it can be for the full life cycle of the parasite as seen with hookworm. If an organism infects your body and causes illness or lowers your quality of health, then it is a parasitic disease.

Another example of a parasitic disease, one that has been in the press recently, for all the right reasons, is the guinea worm (aka dracunculiasis). It may surprise you (or not) to discover that in all of recorded human history we have only ever gotten rid of one disease in its entirety – smallpox. The goal of so many scientists and health officials is to repeat the same again with lots of other diseases, with a focus on vaccines being the magic key to achieve this.

But there are many obstacles to creating vaccines, making it a timely process, so we cannot wait around to create a vaccine for every disease. Although vaccinations have proven successful in many cases, not every disease is suitable for vaccination, and guinea worm is an example of this. Thankfully, in this instance, we did not wait for a vaccine against the guinea worm.

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The Carter Center: Guinea worm coming out of a man’s foot

A guinea worm infection is rarely fatal, but it is pretty horrific nevertheless. People typically catch it from drinking stagnant water that is infected with the larvae of the worm. The sandflies in the stagnant water ingest the worm’s eggs. They are then swallowed by a thirsty human and reach the stomach, where the worm’s larvae are released from the sandfly and enter our system through the intestinal wall. Once in our system, the worm larvae mate and females grow in the abdomen. They can grow up to a meter long and incubate for up to a year before creating a painful lesion on the skin which they emerge slowly through. This is an agonisingly painful process for the host i.e. a human.The cycle is perpetuated when the human places the painful lesion in water to relieve the burning sensation, and the eggs are released into the water to await a new host.

Guinea worm life cycle www.cmaj.ca
The fragile, easily disturbed life cycle of the guinea worm

But if people don’t die from this disease, why has so much effort gone into eradicating it compared to some of the more fatal infections, such as malaria?  It can be explained by two reasons:

  1. Though not fatal, it has a hugely negative impact on people’s lives.
  2. The guinea worm has what is known as a fragile transmission cycle, making it vulnerable to eradication.

“Guinea worm is a particularly devastating disease that incapacitates people for extended periods of time, making them unable to care for themselves, work, grow food for their families, or attend school.” Cartercentre.org

This quote is the reason the “Carter Centre” has dedicated huge resources and time to eradicating guinea worm disease, and why so many partners, such as health ministries, have joined them in their endeavours. The impact the disease has on people and communities is significant and damaging.

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The Carter Center: President Carter comforts a small child as her guinea worm blister is looked at.

As for the second reason, guinea worm will likely soon be eradicated simply because it is relatively easy to do. Unlike malaria or schistosomiasis, which have complicated life cycles and extremely good survival tactics, the guinea worm is a survivor by chance and human-based habits. The transmission cycle is fragile making the guinea worm vulnerable. The cycle is dependent on humans introducing the eggs from the worm into the water by bathing the open wound and then using the same water to drink so we can ingest the infected sandfly. Poor water control and sanitation is the only reason infection still occurs. By changing our habits in relation to water, we can effectively wipe out guinea worm infections as has happened in so many countries so far. So through behavioural changes and improved infrastructure and water management, we are realistically looking at the end of the guinea worm infections.

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The Carter Center: Education was a big part of addressing guinea worm transmission.

The success of this non-vaccine strategy can be demonstrated by looking at the figures. In 1986 3.5 million people a year  were infected with guinea worm in 21 countries throughout Asia and Africa. In 2014 only 126 cases were recorded in 4 countries – Chad (13 cases), South Sudan (70 cases), Mali (40 cases) and Ethiopia (3 cases). This is why talk has moved away from treatment and control, to elimination and eradication. It is a remarkable feat no matter which way you look at it.

Among other examples this intervention sets, it shows the importance of a cross-disciplinary approach to fighting disease. Scientists studied the disease, discovered the transmission route, and defined its cycle. But it was engineers, public health officers, education officers and water sanitation experts that came up with the solutions, and it was policy and political support that implemented the solutions and kept up the momentum needed to achieve this level of success. And it will be crucial now for the momentum to be upheld until we have completely gotten rid of the last few cases without creating any new ones.

The only question is, once we eliminate the guinea worm, what disease will be next? What an exciting question full of possibility that has not been felt since vaccination and the eradication of smallpox. Whether or not the success can be repeated, it makes this achievement and goal no less noble and admirable, and I’m sure it will be the global health accomplishment to beat for the years to come.

The Anti- “Anti-Vaccine Movement”

By Sinéad O’Ferrall (@SineadOFGH)

 vaccine yes no

We have so many effective vaccines against such a wide range of diseases, yet still so many people are dying from these diseases – mainly children, who are the most vulnerable. In 2011 alone, 1.5 million children died from vaccine-preventable diseases. Why don’t people use the available vaccines? Like all things in life there is no one simple answer. However, I will address one reason here – the Anti-Vaccine Movement (AVM).

Unfortunately, vaccines have always been subject to myths and hearsay, which have continued to fuel rumour mills, resulting in a lot of misinformation. As long as vaccines have existed, people have opposed them. In the 18th century, Edward Jenner created the first vaccine targeting smallpox as the historical smallpox epidemic was occurring. But even in the midst of an epidemic with no treatment and a high death rate, Jenner met resistance to his highly effective solution.

I believe the biggest myth prevalent today is the supposed link of autism to vaccination, particularly associated with the measles-mumps-rubella (MMR) vaccine. This myth arose when a paper written by Wakefield was published in the Lancet suggesting the link, however it was quickly disproved and the paper retracted in full. There were glowering inconsistencies in methodology and huge conflicts of interest. Unfortunately, the damage was done. The spark was out there and it quickly developed into wildfire. Wakefield’s study has never been able to be repeated and yet many other studies since have consistently found the opposite result – there is no connection between autism and the MMR vaccine.

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Yet people continue to listen to pseudoscience, fear-mongering and straight up lies, perhaps because it is easier to understand, or perhaps because it is delivered in a cool and hip way on chat shows, hosted by attractive presenters and celebrities who have passion and who people aspire to be like.

We live in a society where fame seems to give people an infallibility that is usually reserved for the Pope. But when it comes to your health, the health of your child, and also that of your neighbour, can we afford to be so careless with the truth?

This is the truth:

According to the organisation Autism Speaks, “Autism spectrum disorder (ASD) and autism are both general terms for a group of complex disorders of brain development. These disorders are characterised, to varying degrees, by difficulties in social interaction, verbal and nonverbal communication and repetitive behaviors”.

While there is no one definite cause demonstrated yet, autism is currently believed to be heavily genetically influenced, with environmental factors also playing a role. These environmental factors include: premature birth, especially if before 26 weeks, increasing age of parents at the time of conception, gender – boys have a four times higher risk, and potentially viral or bacterial infections.

But let me be clear: whilst these are all theories that certainly may play a role, research is ongoing and we have much to learn. One final distinction is, that though these factors may increase the risk of developing autism, they do not cause autism.

The MMR vaccine contains three separate components that protect against three separate diseases: measles, mumps and rubella. These three diseases are all caused by different viruses that cause a variety of symptoms ranging from mild coughs, to the extremely serious condition encephalitis. Encephalitis is swelling in the brain due to inflammation and infection, it can lead to convulsions, brain damage, mental retardation and death (see Amendment 1). These three infections have no treatment post-infection, except for supportive care, so prevention is key.

Measles

These are well established diseases, and there is no doubt about their seriousness and severity. These are not diseases you want to catch or to let your child catch. Now, a lot of AVM followers will say that these diseases are no longer a cause of concern, since no one catches them anymore. But these viruses are still present in nature and without proper measures and continued efforts they will re-emerge.

This is where the vaccine comes in. The MMR vaccine is a live attenuated vaccine (LAV). LAV is a type of vaccine that contains a weakened but still live version of the infectious agent. Scientists manipulate the virus in the lab to replicate again and again until the point of exhaustion, and then use that virus to create the vaccine. This is the best way to stimulate the immune system to create an immune response to the three viruses, with minimal risk to the person. The virus still resembles the version encountered in nature, often referred to as the wild version, and therefore, is most effective at stimulating a strong and accurate response. When a person is exposed naturally post-vaccination, they are protected from the invader.

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Facial swelling in a child suffering from mumps.

The AVM is fueled by the suggestion that rubella has a link to autism, leading people to conclude that the vaccine must also be. But let me put this plainly: study after study has been performed, and no link between autism and the vaccine has ever been established. However, a link to autism and rubella has been investigated with some small link proven. So if you want to protect your child from autism, they have much better odds if they are vaccinated. That is what the rigorously tested evidence says.

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An infant suffering from rubella.

The other big argument that proponents of the AVM call upon, is another ingredient in the vaccine. The main component is the exhausted virus but other ingredients are added to preserve the vaccine and to boost the effect of the immune response. The ingredient that has received the most focus from the AVM is thiomersal. This is a mercury derived chemical that is added for its antifungal and antibacterial properties. But since controversy arose about the vaccine, despite overwhelming evidence to the contrary, it was removed from almost all vaccines as a precautionary measure. It is, however, still used in some flu vaccines. I have included {Amendment One} a small selection of studies looking at the link between thiomersal and autism and other neurological effects, but in summary there is no proven link to date.

Vaccines are often hailed as the single greatest public health tool. Just take the example of smallpox eradication, only made possible by vaccination. Multiple studies show that when vaccination rates goes up, disease rates go down. Vaccination saves the lives of both the individual and protects the community as a whole. If you question or doubt the safety or effectiveness of vaccines that is perfectly okay, it is a complicated field. Find reputable sources of information and critically look at the facts, not the rumours. I would suggest the Center for Disease Control (CDC), WHO’s factsheets, and The History of Vaccine websites as good starting points.

The next time you hear someone shouting out an anti-vaccine statement, that they are harmful or cause some condition or disease, check their qualifications. Check whether they have a Bachelors in immunology or pathology, or even chemistry before you take their word over qualified scientists and doctors, who have chosen their vocational paths because of a desire to help keep the general population healthy.

Recommended studies/ papers for further reading:

Studies reviewing and looking at potential links between thiomersal and autism:

http://www.cdc.gov/vaccinesafety/Concerns/Thimerosal/neuropsychological_Outcomes.html#q6

http://www.immunizationinfo.org/science/autism-and-thimerosal-danish-study

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3018252/

http://www.ncbi.nlm.nih.gov/pubmed/15342856

Targeting Transmission of Tuberculosis

by Line Bager (@lbager87)

On the 11th of November 2014, the London School of Hygiene and Tropical Medicine (LSHTM) and University College London hosted a small conference for the research community to discuss the ways in which Mycobacterium tuberculosis (TB) is transmitted. In a lively talk between Helen Ayles, LSHTM, and David Dowdy, John Hopkins Bloomberg School of Public Health, the prospects of ambitious Active Case Finding (ACF) were debated. Attending this conference as a graduate, with a non-medical and non-scientific background, it was interesting to see what the researchers focused on. The line was drawn rather sharply, perhaps partly for entertainment value, between ACF as a key strategy, actively searching for at-risk individuals, and the opposing view that argued ACF will not have an effect on the rate of transmission overall.

Mycobacterium tuberculosis
Mycobacterium tuberculosis

At the heart of the issue lies TB’s treacherous nature – a person can be infectious for several months before showing symptoms and to make matters worse, symptoms can be confused with many other diseases. During that time, hundreds of people could become infected through the spread of bacteria in the expired aerosols of infected persons. But is ACF really plausible? In a population of millions, how do you find those with TB if you are not testing every single one? From a cost perspective, targeting an entire population simply isn’t feasible. And even if the funds were there, how would you reach the most remote areas? As an economist myself, the pervasive paradigm of cost-benefit analysis is very difficult to escape. As was pointed out at the conference; “TB is not the only affliction of humankind”. The death toll from TB does not come anywhere close to that of heart disease. How much do we actually gain from increasing the spending for ACF? As brutal as it may sound, the funds could probably be spent more efficiently elsewhere.

But let me outline a scenario. Take an individual living in a poor and semi-urban setting, perhaps in Southeast Asia (SEA) or sub-Saharan Africa (SSA). This individual has an insecure income, no formal training, lives in crowded housing and on top of all of this, has active TB. Some might argue that this perpetuates the stereotypical view of SSA or SEA but it is also the reality for many millions of people living there, constrained by their environment. The reality is that many millions of people are facing multiple vulnerabilities and not just with regards to their health. Typically they have no or limited access to health care. TB is not uncommon in many low and middle-income countries, where 96% of infections occur. So it is clear that TB does not target individuals uniformly. In fact, the countries with the highest proportion of TB are Cambodia and South Africa. So even though TB should not be the only disease we focus on, since it hits the poorest and most vulnerable communities, not doing anything is definitely not an option. This little scenario outlines that it is not just the total number of deaths or the level of morbidity that count, but where it happens: whether there is existing infrastructure to reach and treat infected individuals should also be taken into account.

Probable tuberculosis
A case of probable tuberculosis.

Besides, when Helen Ayles advocated for ACF, she wasn’t talking about testing every single individual in every low income country. Maybe she had a fair point when she argued that the so-called ‘TB community’, could be more ambitious and could have a better testing system. Targeting at-risk communities and individuals is a first step. But perhaps it is not a case of identifying people as soon as they are infected but rather before they are so weak that the disease has deprived them of their livelihood and life – which is often the case. It is not a question of chasing every single case of TB as if resources were unlimited, but rather to be more ambitious and exploit possible coordination gains with the screening and treatment of other diseases such as HIV.

A Johannesburg slum: Individuals living in such conditions are disproportionately affected by TB.
A Johannesburg slum: Individuals living in such conditions are disproportionately affected by TB.

In my opinion the question of improving ACF is not getting to the heart of the problem. Asking to what extent ACF can be useful is indeed valid, but it can only have a limited application. It is interesting to note that the decline in TB prevalence happened before the widespread use of antibiotics. What proved the most effective for TB prevention in Europe in the 19th and 20th century were hygiene improvements, nutrition and better housing. Hence, the emphasis on medical advances is sometimes misplaced when it focuses on specific programmes or has a narrow aim. What it boils down to is whether we are targeting the proximate or the ultimate causes of TB. Ultimately, development has historically proven to be the most effective prevention of TB. Hence, structural change in low-income countries is key to generating the resources, underpinning improvements in education, health-care, etc. Therefore, we should never rely on Active Case Finding on its own: it should be secondary to active case prevention – fundamentally improved living conditions.

For videos on the transmission and treatment of TB, click here.

Interview with Prof Jeffrey Lazarus

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Professor Jeffrey Lazarus was being interviewed by Henry Mark for the MSc_GH blog.

Can you identify 2 main challenges and opportunities for health systems research between now and the next global symposium in 2016 (or maybe beyond)?

Just two? Well naturally, the first topic that comes to mind is one at the heart of my work: the intersection of health systems and infectious disease research. We looked at this in a journal issue for the First Global Symposium on Health Systems Research, back in 2010, but it is still under-addressed. I think the global community’s response to infectious diseases in recent years presents some very important lessons relating to health systems dynamics.

During the first decade of the twenty-first century, the channelling of resources into disease-specific programmes, particularly HIV programmes, resulted in many activities happening outside of the national health systems that usually coordinate core functions such as health service delivery and health information management. This approach had its merits at the time. But in the long run, major progress has been made on some infectious diseases while others remain neglected. The fragmented response to infectious diseases needs to be transformed into a health system-based effort to address these health threats collectively, with due attention to how this work relates to other health system priorities.

My second response relates to the journal supplement on people-centred health systems, launched at the recent Third Global Symposium on Health Systems Research. In the words of the editors, the issue is: “putting people first in terms of how services are designed and delivered, and not merely orienting services on the basis of diseases, or for the convenience of clinicians”.

I recently had the opportunity to explore what this means in one specific context when I co-edited a journal supplement on hepatitis and drug use in Europe. A statement by a team of authors from drug user organisations in Spain sums it up perfectly:

Give us voice and respect, more often and in more situations, and we are sure that this will make a difference in the prevention of drug-related harm, including harm from the transmission of hepatitis C and other bloodborne viruses.

How can health systems researchers embrace and support this perspective? That is a key challenge I want to see addressed as the health systems field continues to develop.

How would you like to see health systems – from both research and operational perspectives – positioned in the post-2015 development goals?

Quite simply, I would say that if attention to health systems is not central, we will meet with the same failings that we had with the Millennium Development Goals. The trick is to address urgent issues and save lives, while also positioning ourselves for the long run. Smart health systems research and policy-making is really our only hope for achieving this critical balance.

 

You recently proposed some modifications to the WHO health system framework, and invited interested parties to share their thoughts. At what stage is the process now and what do you envisage/hope to be the overall outcome? 

This was nothing less than a shocking exercise for me. What started as a discussion with a colleague and a short blog post, has turned into a global conversation with more than 20,000 views of the post in just 10 weeks. We are reviewing all of the responses and plan to write up the experience as a journal article. The goal is to help shape how researchers and planners frame their evolving understanding of health systems.

In reality, we believe that the new figure we are finalising represents a major shift that has occurred regarding how people think about health systems, but only a minor change to the building blocks themselves.

 

Finally. A little over 2 years since Health Systems Global was officially born, how has the society met or even exceeded your initial aims and expectations? And what excites you the most about the society’s work in the coming years?

It’s hard to know where to begin – we have more members than ever, a large symposium surplus to help us prepare for the Fourth Global Symposium and an engaged membership and health systems community. What I find exciting are the unanswered questions about how we will develop. When I co-founded Health Systems Global in 2012, our central goal was to run the global symposium. Now we have nine active thematic working groups and are heavily engaged in social media.

Where Health Systems Global goes from here will depend very much on the priorities that emerge from members’ ongoing discussions, both in thematic working groups and in other fora, and these priorities cannot be fixed in a static agenda. The health systems community’s response to the Ebola crisis is a good example of how unforeseen global events challenge us to think and work in new ways. Flexibility will be the watchword for Health Systems Global. I am eager to see how the organisation continues to dynamically reconfigure itself in accordance with the always-changing nature of health systems themselves.

Jeffrey V. Lazarus is a senior researcher at CHIP, the Centre for Health and Infectious Disease Research at the University of Copenhagen. He is the secretariat director of Health Systems Global. Follow him on Twitter at @JVLazarus.

Spotlight on Europe

By Henry Mark (@henrymark88)

The first guest post on the MScGH blog from Jeffrey Lazarus provides a number of key insights into the challenges of combating viral hepatitis in Europe; and it certainly will be a challenge. Yet there is room for optimism, as one of only 4 disease-specific world health days we can all hope that viral hepatitis is getting some of the recognition it needs. Developments, such as new Hepatitis C virus (HCV) treatment, can only help increase the profile of this group of infectious diseases, yet with each development comes new questions, like how can these new very expensive drugs be delivered in an equitable manner to all who could benefit?

There are some broader themes within the article that will resonate with people from different sectors and specialities.

Overall I was left querying our global health perspective of Europe. It seems somewhat ironic that as global health students and professionals we are continually looking to travel thousands of miles to low and middle-income countries away in search of a worthy challenge, while often little precedence is given to the challenges we face closer to home. Hepatitis is a clear example of this. Perhaps the lure of travel or personal exploration draws us far afield, but we should all keep in mind Europe is no utopia, with issues equally deserving of our attention.

The second part of the article that resonated with me is the issue of moving forward with the implementation of programmes and policies that are only supported by patchy evidence. In all areas of science, programmes and policy we face a common conundrum, how to progress in the face of unknowns. In many scenarios it’s all too easy to be frozen to inaction. Yet academia moves at a pedestrian pace, making filling the evidence gaps a somewhat aroused process. In the mean time we have to ensure we use what knowledge we do have to its full potential. I think Jeff makes a vital point about working with the whole community on this aspect. Academic research is but one piece of the puzzle, a huge amount can be learnt from programme implementers, policy makers, activists and patients that can help bridge information gaps and ensure we keep moving forward.

It is great to see hepatitis getting some coverage and I would highly recommend following the events at the upcoming ‘European HCV Initiative’ conference on the 23rd-24th of this month.

Hepatitis in Europe – the hidden epidemic

The very first guest post on the MScGH blog comes from Professor Jeffrey Lazarus and is a repost of a recent article he wrote for the BioMed Central blog. Jeff is the Secretariat Director of Health Systems Global, a senior researcher at the Centre for Health and Infections Disease Research in Copenhagen and also guest lecturer for the MScGH programme. This article is accompanied by some reflections from MScGH student and the blog series editor, Henry Mark

When is it important to gather more evidence to inform the response to a major public health problem, and when must we act on the limited available evidence in order to save as many lives as possible? As I worked with my colleague Kevin Fenton to prepare a supplement published by BMC Infectious Diseases on viral hepatitis and drug use in Europe, I found myself reflecting often on this question.

It weighed on my mind in part because of the scale of the problem: the World Health Organization European region has an estimated 15 million people living with the hepatitis C virus (HCV), and two million of these people are thought to be current injecting drug users. The practice of sharing injecting drug equipment is widely recognised to be one of the key drivers of Europe’s hepatitis C epidemic today.

There is a need for swift action to fill a policy and programmatic void in many European countries regarding viral hepatitis prevention and treatment services for people who inject drugs. Growing recognition of this situation has helped to catalyse widespread interest in the first European Conference on Hepatitis C and Drug Use, slated for 23-24 October 2014 in Berlin.

We anticipate that many of those people who attend or follow the conference will find themselves grappling with a common challenge in its aftermath: how to move forward, whether on HCV prevention, treatment, surveillance, advocacy or other fronts, when there are so many gaps in the body of evidence that should be guiding us.

Case in point: the review article that I co-authored for this supplement. The article examined HCV treatment uptake levels among those who inject drugs in Europe. Key factors such as drug use, eligibility for HCV treatment, and criteria for when treatment should be initiated were conceptualised in such different ways from one study to another, that the review exercise left us reluctant to make any sweeping pronouncements about the extent to which drug users with hepatitis C are accessing treatment.

For studies reporting on treatment uptake levels among current injecting drug users – a critical issue from the standpoints of both disease control and human rights – only one of the 25 studies included in our review provided this information. But if someone were to ask me how many people who inject drugs with hepatitis C in the WHO European region are accessing treatment, I would emphatically respond, “Not nearly enough. And we need to do something about this – now.”

In other words, wrinkles will need to be ironed out of the evidence base before we can confidently put forth a HCV treatment uptake level for drug users that seems relatively precise. But do we really need a number in order to intensify advocacy efforts on behalf of those who need treatment?

Safe injection kit
A safe injection kit

Whether the real proportion is 30%, or more, surely almost everyone who works in this field would agree that making HCV treatment more accessible to those who inject drugs is a key advocacy and public health goal.

Unfortunately our current knowledge about many aspects of the health issues facing people who inject drugs is limited in ways that threaten to undermine the development of a cohesive European-wide response to the HCV epidemic in this population.

How, then, should decision-makers in this arena determine whether or not to move forward with strategies only weakly supported by the available evidence? There are no easy formulaic answers to such a context-specific question. But what I have learned from co-editing the supplement on viral hepatitis and drug use in Europe is that it is essential to involve the voices of diverse constituencies in this process.

I already would have taken that stance on principle; what strikes me now, after working closely with many of the supplement authors over a period of a year, is just how much wisdom and experience the community has to share.

I use the word “community” broadly in this instance, not to refer only to community-based organisations or civil society actors, but rather to the entire community of people who are increasingly drawn together by their shared outrage about societal neglect of people who inject drugs.

This community includes researchers, policy-makers, advocates, activists, programme implementers, and those PWID who are reaching out to all of the rest of us in an urgent attempt to make their needs better understood.

Several impressive examples of this community’s insights, drawn from both empirical research and lived experience, can be found in the aforementioned supplement. I greatly look forward to being further wowed when I attend the Berlin European HCV Initiative conference on 23-24 October 2014.

By. Jeffrey Lazarus (@JVLazarus)

Out of the Cold

By Andrea Stanglmair

For decades, distribution of vaccines in Africa and other warm regions have been hampered by the need to keep vaccines refrigerated. An immunization campaign in Benin has shown that vaccines can be delivered to remote areas without using ice boxes, and yet still remain viable. The challenges of keeping vaccines cool appear at every step of the production chain from manufacture to use. Most vaccines must be kept cold, at temperatures between 2 and 8 degrees Celsius – a major challenge in remote areas without electric power. But the World Health Organization says a new vaccine aimed at preventing Meningitis A can be stored for up to four days at up to 40 degrees Celsius, without any loss of potency, efficacy or safety. This could really change the way mass vaccination campaigns are conducted in remote or low-resources settings.

Vaccination Campaign in West Africa

Conducted as part of a meningitis A vaccination campaign in Benin in 2012, a recently published study in the journal Vaccine represents a breakthrough not only for the vaccine MenAfriVac, but potentially for increasing the efficiency, coverage, and affordability of other lifesaving vaccines as well. Especially in remote, hard-to-reach areas where keeping the vaccine cold is difficult. MenAfriVac was first introduced in 2011 in a mass vaccination campaign in Africa’s meningitis belt. However it was not until the Benin trial that the vaccine was administered outside of the cold chain. The Benin study aimed to assess and demonstrate for the first time the feasibility and acceptability of using the Controlled Temperature Chain (CTC) approach in a massive vaccination campaign, rather than keeping the vaccine within the traditional recommended 2°to 8°C temperature range at all times.

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 Cutting Costs

Findings from the study show that the new flexibility makes it easier for vaccinators to reach ‘the last mile’ – the time from when the vaccine leaves the refrigerator at the district health center until it is injected. Vast resources are spent on the cold chain system, such as acquiring and transporting freezers, ice packs, transportation fuel, electricity fuel, ect. Sometimes, it is not only costly, but it is also very challenging to reach remote areas with such constraints. Additional transportation and human resources costs are also incurred when vaccines, cold boxes, and fresh ice packs need to be replenished. Not having to worry about freezer packs nor having to return to the district health center each day to replenish vaccine supplies means that health staff could vaccinate more people in a shorter amount of time and reach more remote areas. The potential gains by such vaccines extend beyond health. Removing the refrigeration requirement could also reduce costs. A related study by WHO looked at the economic benefits of transporting vaccines at ambient temperatures. Working outside the cold chain for a limited time could cut storage and transportation costs in half. As a result of the cold chain requirement, there is normally a lot of wasted vaccine vials during immunization campaigns. Normal wastage during vaccination campaigns can be as high as 5 percent, because as soon as the 2 to 8 degree temperature range is exceeded, the vaccine must be discarded.

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Hopes for the Future

“In many countries where the cold chain is critical and can be a challenge, this new innovative approach could be a game changer,” says Stefano Malvolti, director of vaccine implementation at the GAVI Alliance, a public–private health partnership based in Geneva. The next step will be for pharmaceutical developers to see if the refrigeration requirements for other vaccines, such as yellow fever and cholera, can also be changed and being approved for CTCs. Many vaccines are actually thermostable outside the recommended temperature range, and some newer ones in particular can often remain viable for days, weeks or even months after exposure to higher temperatures. CTC would allow vaccines to be stored for short periods at higher temperatures for the ‘last mile’ of distribution, especially helpful in hot developing countries where electricity and refrigeration is lacking. If widely used, the approach could significantly reduce the cost and logistical challenges of reaching people living in remote areas and remove a major constraint to achieving universal coverage with vaccines.

Sanitation – Friend, Enemy or Perhaps Both ?

By Pernille Klarskov Stage and Martin T Jepsen 

In today’s society most health issues are discussed in both developing and developed countries to a smaller or larger degree. In some developing countries proper sanitation practices are still in it’s infancy, and in developed countries the question of the possibility of being ‘too clean’ is an ongoing debate.

In Scandinavian society, going to the restroom is regarded as a mundane part of everyday life. It is something we do not really talk about and what happens when the door is locked, we keep to ourselves. However, a third of the world population does not have access to proper sanitation where 1 billion do not even have access to a toilet !

The absence of proper sanitation facilities can be experienced when travelling. Once you get over the absence of a toilet seat and have to squat, you eventually want to flush. Many places will only have a water container and a large ladle to flush with. In some places the search for soap may be futile and therefore only water is used for hand washing. Subsequently this does not remove the germs on the hands which can lead to the spread of bacteria which may cause infections.

In countries where electrical home appliances are less available, people still have the same needs.  Hence clothes washing, showering, dish washing, tooth brushing must then take place outside the house. This subsequently leads to the use of alternative water resources that may be very unsanitary.

It is not only the standard of toilets that is an issue in many countries. In many developing countries the rate of urbanisation is rapidly growing to an extent where than city planners can’t keep up with the demand. This means sewage systems may not be installed before the houses are built leading to discharge of water in various places, which often ends in a stream or river with human and environmental consequences. A study has shown a correlation between poor sanitation and stunting in India.

Flicr – Indiawaterportal.org
Flickr – Indiawaterportal.org

As developing countries struggle to meet sanitation requirements, most developed countries have not had this problem for many years. In 1889 the invention of the automatic storage water heater by Norwegian Edwin Rudd, led to it being much easier to take a shower. The increase in atopic diseases over the years have made some scientists speculate that being too clean might be the cause , and in 1989 the so-called Hygiene Hypothesis was presented by Dr. David P. Strachan. Since then there has been great discussion about the validity of this hypothesis. Scientists agree on the fact that proper sanitation practices are crucial in order for infectious diseases not to spread. Furthermore many skin conditions require proper cleaning every day in order to keep moist and bacterial infections at bay.

In a publication from the Journal of Clinical and Experimental Allergy entitled ‘Too clean, or not too clean: the Hygiene Hypothesis and home hygiene’ (Bloomfield et al. 2006), the myth that being too hygienic is a direct cause of the increase in atopic diseases is dismantled. However the report argues that there is some evidence to support the link between decreased exposure to microbial and autoimmune diseases such as childhood diabetes and multiple scleroses. With this information in mind policy makers could find it difficult to create appropriate guidelines where proper sanitation practices are met. If more microbial exposure is needed, how do you ensure this without compromising the protection of infectious diseases? The International Scientific Forum on Home Hygiene, have attempted to create guidelines that target the risk areas in the household by directly focusing on activities such as food preparation. This approach would assist in ensuring microbial activity without compromising proper hygiene practices, however it is a complicated matter that needs further research.

Flickr - Chip Nestor
Flickr – Chip Nestor

It is clear that extensive reports could be written on both of these two issues of sanitation. For now the most important issue to be addressed, must be to ensure that there is adequate clean water and proper restroom facilities for developing countries. There is no doubt that proper sanitation practices will assist greatly in eliminating pathogenic bacteria in these countries. On the other hand decreasing microbial exposure in developed countries could possibly have long term effects that we do not yet know about. Further research in this area is therefore also needed.